Johnson, Karin PhD; Hagopian, Amy PhD, MHA; Veninga, Catherine PhD; Hart, L Gary PhD
At least 17,000 physicians who received their medical school training abroad but who currently practice in the United States are known to have been born in the United States. Such schooling abroad began during the early 1900s, when training in European schools was thought to complement a physician’s education.1 In the 1930s, some prospective American physicians who were denied admission at U.S. medical schools turned to Europe for medical training.2
Beginning in the 1950s, an increasing number of Americans trained abroad, either as a first choice or because they failed to obtain entrance into U.S. schools. Between the 1950s and the mid-1970s, openings at U.S. medical schools increased, but admission became more difficult and the number of slots declined relative to residency program opportunities. Competition in the United States, coupled with the ability to return there for residency training, made overseas medical education attractive for U.S. students, especially in Italy, Belgium, Spain, France, and Switzerland.3 However, in response to rising demand for medical education from their own citizens, European schools placed restrictions on the admissions of American students.4 Existing schools in Mexico, particularly the Universidad Autonoma de Guadalajara, responded by increasing recruitment of U.S. students. Additionally, new “offshore” foreign schools opened during the late 1970s and the early 1980s. These schools differ from other foreign schools in that they operate almost entirely for training U.S. citizens. The first such offshore school, St. George’s University in Grenada, opened in 1977; almost two-dozen other offshore schools appeared between the mid-1970s and mid-1980s throughout Mexico and the Caribbean, with a few in Central America and the Philippines.5 The growth in offshore schools continued into the 1980s, but then declined. Academic and policy attention to U.S.-born, foreign-trained physicians has similarly waxed and waned. To our knowledge, only one recent peer-reviewed article6 has substantively addressed the topic.
American-born physicians have continued to graduate from foreign medical schools, but there is little information on which countries those schools are in and how the current number (about 17,097 in active practice in the United States in 2002) compares to previous years. This paper studies U.S.-born international medical graduates (USIMGs) in order to analyze their changing numbers and the geography of where they train. How many are there? Where do they train? Has this changed over time? What changes might we expect in the future?
It is crucial to explain exactly who we counted as USIMGs in this study. Country of medical school graduation, rather than citizenship, defines the international medical graduate (IMG) label, formerly often called foreign medical graduates. Thus, all students who attend medical school outside the United States are considered IMGs, even if they are U.S. citizens. U.S.-born physicians who graduate from medical schools abroad make up the subcategory of USIMGs. The single exception is graduates of Canadian medical schools; most physicians who attend medical school in Canada (7,989 of active physicians in the United States in 2002) are not considered IMGs. The rationale behind excluding Canadian physicians from the IMG definition is that the Canadian medical education system is similar to that of the United States. The Liaison Committee on Medical Education (LCME)—the body that accredits U.S. medical schools on behalf of the Association of American Medical Colleges (AAMC) and the American Medical Association (AMA)—and the Committee on Accreditation of Canadian Medical Schools have a cooperative process of accreditation. Canadian-born physicians are, however, still subject to relevant immigration requirements.7
U.S. students who have trained abroad but wish to return to the United States for the last part of medical school or for residency training have three options: transfer to or pursue a clerkship through a U.S. school, apply for residency positions through the Educational Commission for Foreign Medical Graduates (ECFMG) process, or, from a few schools that meet program guidelines, enter the Fifth Pathway program. This program was established in 1971, so named because it provided an additional route into hospital residency programs beyond the four that previously existed (graduation from a U.S. medical school; certification by the ECFMG; full and unrestricted licensure by a U.S. licensing jurisdiction; and passing the Spanish language licensing examination in Puerto Rico8). It provides an opportunity for one year of clinical training in New York state that circumvents the otherwise mandatory fifth-year internship in Mexico that U.S. students and educators argue is inappropriate, and thus unnecessary, training for U.S. practice.9 Fifth Pathway students can enter residency training without ECFMG certification or a medical degree granted in the United States. Most residency programs and state medical licensing authorities accept the Fifth Pathway program as a qualification for medical practice. In 2004, 171 National Resident Matching Program (NRMP) applicants were Fifth Pathway participants.10
To assess USIMGs’ characteristics, we conducted a cross-sectional analysis of the March 2002 American Medical Association (AMA) data for active physicians.11 We analyzed data on the 682,185 active, patient-care physicians working in the United States in 2002, including residents. Of these physicians, 477,140 (69.9%) were born in the United States, 6,639 (1.0%) were born in Canada, and 104,667 (15.3%) were born in countries other than the United States or Canada. Birth country data were missing for 93,739 (13.7%) physicians, including for 44.9% of graduates from foreign medical schools. We excluded federally employed physicians, such as the in prison or VA systems. They constitute about 2% of U.S. physicians and workforce research typically regards them as not directly comparable to non-federally employed physicians. We produced descriptive statistics on country of birth, country of medical school training, and year of training for all foreign-trained physicians whose birth country is known. We confined the analysis to physicians engaged in direct patient care because most policy and academic interest in USIMGs pertains to physicians engaged in clinical practice. We also analyzed NRMP10,12–14 statistics, and reviewed published data on ECFMG certificates awarded to U.S. citizens,2 foreign medical school Web sites, and published literature. We used the AMA data for all analyses, unless otherwise noted.
This study was conducted from 2003 to 2004 at the Center for Health Workforce Studies, University of Washington. It was approved by the University of Washington institutional review board.
How many USIMGs are there?
According to AMA data, a total of 17,097 patient-care physicians practicing in the United States in 2002 and known to have been born in the United States graduated from medical schools abroad. These physicians made up 11% of all foreign-trained physicians and 4% of all U.S.-born physicians in U.S. practice in 2002. Our analysis is based on these USIMG physicians (i.e., those known to be both U.S.-born and graduates of foreign medical schools). An additional 1,565 USIMGs were employed in the United States in a non-patient-care capacity.
In which countries and schools do USIMGs graduate from medical school?
Known USIMGs trained in 83 countries, in all parts of the world. Ninety-four percent (16,107) of USIMGs graduated from medical school in only 20 countries, as depicted in Table 1. Further, 58% (9,866) graduated from schools in the Caribbean and Mexico alone, and when limited to only graduates during the last decade, that number rises to 65% (1,417). The top five countries from which USIMGs practicing in the U.S. in 2002 had graduated were Mexico, Italy, Grenada, the Dominican Republic, and Montserrat.
Table 1 illustrates that countries that train the most USIMGs produce a relatively higher proportion of USIMGs to foreign-born IMGs compared to other foreign countries. This pattern suggests that the schools that graduate a large number of USIMGs focus on training U.S.-born students who ultimately practice in the United States, although this observation is difficult to document in the absence of comprehensive data from multiple countries. Over half of the IMGs practicing in 2002 in the United States who were trained in Mexico, Italy, Montserrat, Switzerland, and Belgium were USIMGs. At least 20% (4,434) of IMGs from Grenada, the Dominican Republic, Dominica, Israel, the Netherlands, and France were also known to be U.S.-born.
In addition to training in only a handful of countries, most known USIMGs come from just a few dozen medical schools. Only 25 schools in the world have graduated more than 100 current USIMGs. In total, they have graduated 75% (12,762) of currently practicing USIMGs. These schools are located in 11 countries: Mexico, Italy, the Dominican Republic, Philippines, Switzerland, Belgium, Ireland, Grenada, Montserrat, Dominica, and Israel. In the 1980s, two schools, Universidad Autonoma de Guadalajara in Mexico and St. George’s University School of Medicine in Grenada, each graduated more U.S.-born physicians currently practicing in the U.S. than the average U.S.-based school (1,455 and 1,021 respectively, compared to 956). In the 1990s, the top five medical schools from which USIMGs graduated were St. George’s in Grenada, Ross University in Dominica, American University of the Caribbean in Montserrat, Tel Aviv University in Israel, and Universidad Autonoma de Guadalajara in Mexico. Individual schools in France, Italy, the United Kingdom, the Dominican Republic, and Montserrat have graduated more U.S.-born doctors that now practice in the United States than nationals of their own countries who now practice in the United States.
Some USIMGs graduated from medical schools in countries that produce very few USIMGs (for example, Indonesia, Libya, Papua New Guinea, Uganda, Tanzania, and Zambia). These physicians are likely influenced by unique personal circumstances, rather than attending schools that are actively recruiting U.S. students.
Have the countries in which USIMGs train changed over time?
The pattern of foreign countries and schools where known USIMGs have trained has changed from the 1950s to 2002. As Figure 1 illustrates, the majority of currently practicing USIMGs who trained in Europe (especially Belgium, France, Germany, Greece, Ireland, Italy, the Netherlands, Spain, Switzerland, and the UK) and Mexico graduated before 1980. This pattern shifted remarkably during the 1980s; the majority of USIMGs who trained in Caribbean countries (especially Dominica, the Dominican Republic, Grenada, and Montserrat) graduated in 1980 or later. Columbia, Israel, the Philippines, and Poland have also graduated a relatively large number of USIMG, most of them from 1980 onward. Only four countries have continued to train large numbers of USIMGs into the 1990s: Dominica, Grenada, Israel, and Montserrat each graduated over one-quarter of their currently practicing USIMGs in the 1990s. A recent analysis using data on the number of ECFMG certificates issued to U.S. citizens shows these trends continuing dramatically into the early 2000s.6
A dozen countries began to train or expanded their training of USIMGs in the 1990s: the Netherlands Antilles (in the Caribbean), Nigeria, Hungary, Thailand, Saudi Arabia, Sudan, Belize, Indonesia, Libya, Papua New Guinea, Uganda, and Tanzania. Schools in these countries are not just training Americans, but may be recruiting an international student body. For example, health sciences students at Hungary’s University of Debrecen in the 2003–2004 academic year included 82 Americans, 75 Iranians, 182 Israelis, and 202 Norwegians.15 Some countries that graduated small numbers of USIMGs in the past did not do so in the 1990s. These countries include Portugal, Honduras, Japan, Denmark, Iceland, and Zimbabwe.
This analysis used a current cohort to describe retrospective patterns, which potentially introduces error. To validate our analysis, we compared the AMA data on USIMGs who had graduated between 1969–1982 with information on U.S. citizens* who sat for the ECFMG examinations from 1969–1982.2 Overall, Dublin and colleagues’ numbers (but not proportions) were higher than were those reported by the AMA, which is explained by the common phenomenon of students taking the written ECFMG examination more than once. The rank order of Dublin’s country graduation data were largely consistent with ours.
Will the number of USIMGs grow, decline, or remain stable?
According to AMA data, about 44% (7,502) of currently practicing known USIMGs graduated from medical school between 1981 and 1990. Only 12% (2,074), however, graduated after 1990, which suggests that the number of USIMGs may be leveling off. We compared this observation to the NRMP data. Most students are placed in residency positions through the annual residency match, so NRMP data are good indicators of trends in the physician pipeline.
Our analysis of NRMP data does not support a downward trend in USIMGs. Figure 2 shows a decline in the number of USIMGs who matched beginning in the 1980s (Fifth Pathway and otherwise), but in the mid-1990s match rates and numbers began to increase again. In general, IMG match trends follow those of all other applicants, but periods of increased competition for residency positions, especially in the late 1980s, have affected foreign-born IMGs most, indicated by a relatively small percentage of matches. The apparently smaller number of USIMGs in the 1990s than in the 1980s may indicate that foreign-educated physicians enter the U.S. pipeline more slowly than domestically educated physicians. Over the next few years, additional USIMGs who trained during the 1990s will probably enter U.S. practice. The analysis by McAvinue et al.6 showing an increase in the number of ECFMG certificates granted to U.S. citizens between 1992 and 2002 lends further support that the number of USIMGs in U.S. practice will grow.
Our findings show that Americans continue to attend medical school abroad in large numbers. NRMP data indicate that over 1,000 USIMGs have entered the physician workforce each year between 2000 and 2004, suggesting a new growth spurt surging from a low of 166 USIMGs matching to residency positions in 1995. A small number of U.S.-born physicians have trained at foreign medical schools for decades. However, the geography of where the majority of students train has changed over time, with a notable decline in the portion training in Europe and an increase in the number training in the Caribbean, India, and Israel. A variety of other countries also continues to provide U.S. students with medical school training.
The USIMG influx from offshore schools in the 1970s diminished during the 1980s when competition for residency positions increased.16 Simultaneously, opinions of politicians and educators about USIMGs, and particularly offshore schools, became increasingly negative between the early 1970s and late 1980s. Debates about the quality of offshore schools, fueled by General Accounting Office site visit reports in 198017 and 1985,18 were prominent, playing out on the pages of The Lancet 19,20 and The New England Journal of Medicine. 21,22 A series of efforts to increase the quality of foreign-trained physicians ensued. These included increasing prelicensure testing of foreign-trained physicians and state or federal standards restricting graduates of inferior schools from proceeding to important milestones in the medical education process—internship, residency, or state licensing. For example, New York State, which provided a major conduit to U.S. practice for offshore medical students by offering structured clinical clerkships, established a series of quality standards for clerkships in the early 1980s. It established a medical skills knowledge examination and classified graduates of certain schools as unapproved for entry into residency in the state.4 By 1986, the number of IMGs dropped slightly below 1980 levels and the proportion of USIMGs declined to near where it had been in 1982.
Existing literature does not account for the currently continuing and possibly increasing entry of USIMGs into the U.S. physician workforce. This phenomenon can be attributed to the continued competition for U.S. medical school positions and declining attention to the quality of training provided in foreign medical schools in the wake of previous quality improvement efforts. Efforts to limit the entry of unqualified physicians into the U.S. system continue—for example, the addition of the Clinical Skills Assessment portion of the ECFMG examinations in 1998 and the adoption of new state and federal standards that restrict graduates of medical schools considered to be inferior from entering internship, residency, or state licensing.
In a move that recognizes the continued importance of foreign schools in training U.S. physicians, meanwhile, the AAMC is planning site visits to offshore schools to help U.S. medical education and licensing bodies better assess the suitability of the curriculum at foreign schools for U.S. practice, perhaps even leading to foreign medical school accreditation. These developments may provide additional opportunities for U.S. students to attend medical school abroad and easily continue into U.S. residency programs.
Also missing from the literature is documentation of students’ perspectives on pursuing undergraduate medical education overseas. Popular perception is that USIMGs train abroad because they could not get into U.S. medical schools, but this assertion is unsubstantiated. Cost, family ties, or interest in new experiences may all contribute to the continuing number of students who choose this option. Further study of this issue is warranted.
The AMA data we used as the primary data source for this analysis introduce some limitations to the study. First, we assessed retrospective patterns based on a current cohort. However, our comparison with the analysis of ECFMG certificate data shows this limitation appears to be small. Second, of the information in our source, data about the most recent IMGs are the least complete since it takes some time for these physicians to enter the U.S. medical workforce pipeline and for relevant data to be recorded in the AMA data file. Third, the AMA file lacked birth country information for 93,739 (13.7%) physicians. We assume that most of these physicians are foreign-born since 69,572 (74%) of them were foreign-trained. Said another way, 69,572 (44.9%) of IMGs were missing country of birth compared to 24,167 (4.6%) of U.S.- and Canadian-trained physicians. However, it is probable that some of these physicians are U.S.-born; thus our analysis probably undercounts USIMGs. Fourth, birth country information can be unreliable, and apparent trends in countries producing a small number of USIMGs may reflect data errors.
Because the AMA dataset is a secondary data source, it prevents us from fully understanding some of the patterns that we described in this paper. Additional research is required to comprehensively answer questions about why students go to foreign schools and why foreign schools recruit U.S. students. Finally, primary data collection from foreign schools would be required to learn more about what percentage of all graduates of foreign schools (not just those that practice in the U.S. after graduation) are U.S.-born.
While only 4% of U.S. physicians known to have been born in the United States attended medical school in foreign countries, these physicians represent at least 11% of the physicians we call IMGs. The majority of these USIMGs trained in just a dozen countries and at just two dozen medical schools. Several foreign medical schools have contributed more graduates to the current practice pool than have U.S. medical schools. The places where U.S.-born students now primarily attend medical school seem to have shifted in the 1970s. Schools in European countries became less prominent and relatively new schools in Caribbean countries became more popular. This pattern changed little in the 1990s and 2000s. However, two new developments are under way: (1) greater popularity of schools in different countries than before, especially Hungary, Costa Rica, and Israel, and (2) students who successfully enter U.S. practice graduating from a smaller number of schools. Additionally, the debates about USIMG quality that accompanied the shifting geography in the 1980s have subsided over time, even as the number of USIMGs appears to increase. This analysis shows that USIMGs are an enduring but dynamic part of global physician migration patterns. USIMGs will remain an important part of the U.S. health workforce in the foreseeable future. Researchers, residency programs, medical licensing authorities, and federal policymakers should continue their efforts to understand why U.S.-born students pursue medical education in other countries, and how to prepare and certify those who return for medical practice in the United States.
This study was funded by the U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Analysis, Grant No. 6 U79 AP 00003–06.
The authors express their gratitude to Meredith Fordyce for her insightful commentary and assistance with analysis.